As benefit specialists for Kaiser Permanente affordable medical insurance, the role of our health insurance agents is to understand the personal medical care needs of guests and to educate them on the options that best fits their situation so that they can make an informed decision in selecting the plan that’s right for them, their family, or their business. Below are some common scenarios that come up frequently and the plans or resources that are often recommended. Perhaps, you will find answers to your own situation in one of these examples.
Scenario 1: When a Guest Needs an Affordable Plan
Here, the goal is to find coverage that balances the monthly premium with the cost for the health services. To help narrow the health plan choices, clients will be asked these diagnostic questions:
• “What types of medical services do you tend to need or are most concerned about?”
• “Is there a budget range that you would like me to work with?”
Plans that carry a deductible tend to have the lowest premiums. The higher the deductible, the lower the premium. We’re likely to recommend a high deductible plan if the individual rarely needs services and especially if they just need coverage for a short period of time, because they’re in-between jobs, or waiting to be eligible for Medicare, for example. For these individuals, here are the plans that work well for many people who are in a similar situation:
• $40/3000 Deductible Plan. This is the least expensive plan that includes doctor visits and prescription coverage without a deductible. This policy would be a good fit if you don’t need maternity coverage.
• $40/2000 Deductible Plan. This policy works like the $40/3000 Plan except it includes pregnancy benefits. Also, the deductible and the maximum that you would pay out of pocket are considerably lower.
• The $0/5000 HSA Deductible Plan. This is one of the most affordable major medical plans Kaiser Permanente offers. It’s for people who rarely need services and mainly want basic coverage or catastrophic protection.
Scenario 2: When a Person Has Pre-Existing Conditions and is Concerned About Qualifying
Here, the primary goal is not as much finding the right plan as it is finding a way to qualify for health insurance. Below are some points to consider:
• Applications for Kaiser Permanente individual and family coverage are underwritten for severe, recurring, or chronic conditions, which could result in a non-approval. Even if you have a medical issue, often, it is still a good idea to apply so that underwriting can review your particular situation.
• When someone wants a better idea of their chances for approval, we may go over some broad examples, like those listed below:
a. Persons with a mild case of asthma only could still get approved in certain cases.
b. Persons who have asthma but who’ve also had an emergency visit the last year, or are a chain smoker, overweight, and also have high blood pressure, might not be approved. Since eligibility is based on a case-by-case basis, it would be advisable to still submit an application so that underwriting can review your personal situation. Keep your current plan active until you hear back from underwriting.
• If you own a business, we might explore the possibility of qualifying for group insurance. Typically, company health plans are not subject to medical review so a denial for pre-existing conditions may be a non-issue.
• The last resort for people with a high likelihood of being declined would be to offer them the phone number to MRMIP (‘Major risk Medical Insurance Program’, phone # 1-800-289-6574), which is a state-facilitated health program that is designed to cover people who’ve been denied previously.
Scenario 3: When an Individual is Getting Health Insurance on Their Own for the First Time
Generally, we’re talking about a young adult who is coming off of their parent’s plan, or a recently divorced individual who lost coverage. Also, this could involve a newborn or a newly-adopted child. To help you plan for the best health coverage for your baby, click common baby conditions.
Since the reason for needing health insurance for the first time is generally accompanied by a financial constraint, the goal for these individuals is to find a low-priced option that still gives them the benefits they need most. Some popular resolutions for people in this boat are:
• For a young adult who is no longer eligible for coverage under their parent’s plan:
See the three plans recommended under the section marked, ‘When a Guest Wants an Affordable Plan’.
• For a recently divorced individual who lost coverage:
a. When the person has pre-existing conditions, see the section marked, ‘When a Caller Has Pre-Existing Conditions and is Concerned About Qualifying’.
b. When there are no pre-existing conditions, jump back to the three plan recommendations under the ‘Affordable Plan’ section.
• When the insurance is for a newborn or newly-adopted child:
This can be a little more involved because, generally, the premium for a child under age 19 can be steep, especially for newborns. If the child has a pre-existing medical condition, the premium may be more. For infants and new adoptees, the most cost-effective option could be group insurance, if at least one parent or a legal guardian qualifies. Generally, it’s best to go over your personal situation with an insurance representative. For a Kaiser benefits specialist, call 1-800-514-0958.